The mental health care labyrinth

For people suffering from depression, misinformation abounds. Drugs work — or do they? Talk therapy is the answer — or is it?

Parsing through the contradictions not only shows how treatment is far from being one-size-fits-all, but also reflects changes in the field of mental heath care and an increasing disparity between psychiatry and psychology.

A recent analysis released by the American Medical Association revealed that for patients with less severe depression, antidepressant medications are just as effective as using a pill placebo. The study looked at the effects of only two kinds of drugs: Paxil, a selective serotonin reuptake inhibitor or S.S.R.I., and imipramine, an older, generic drug in the category known as tricyclics. Prozac and Lexapro have similar effects as Paxil.

For those with severe depression, the drugs provided substantial relief. But most people with moderate or mild depression improved just with talk therapy and a placebo pill. Robert J. DeRubeis, a co-author of the AMA study and a professor of psychology at the University of Pennsylvania, says that the placebo effect works “pretty well” for these patients in the short run.

Such a public inquiry into the usefulness of antidepressants caused an uproar in the mental health world. Richard A. Friedman, a professor of psychiatry at Weill Cornell Medical College, wrote in a New York Times article that the study “contradicted literally hundreds of well-designed trials, not to mention considerable clinical experience.”

Critics of the findings say that it could dissuade patients from seeking drug therapy. Achieving remission for patients with depression can also involve multiple attempts at finding the right drug. According to a survey published in January in The Archives of General Psychiatry, only half of the Americans suffering from major depression are already getting treated, and a mere 20 percent are getting the necessary care outlined by the American Psychiatric Association.

These percentages plunge even lower when looking at specific populations such as African Americans and Mexican Americans, who are among the least likely to receive adequate care. When factoring in aspects like economic feasibility or social stigma, it’s clear that access and awareness are crucial when it comes to mental health treatment.

Psychiatrist Daniel Carlat, the author of “Unhinged: The Trouble with Psychiatry,” thinks the current model of psychiatry has become flawed, privileging medication at the expense of other treatments. “Both meds and therapy are crucial,” Carlat writes on his blog. “The ultimate mental health practitioners, in my view, should be equally skilled at both psychopharmacology and psychotherapy.”

An increase in antidepressant usage can be attributed to a rise in the availability of medications, as well as decreased insurance coverage of psychotherapy. The amount of psychiatrists who proffered talk therapy at all of their patient visits dwindled from 19 percent in 1997 to 11 percent in 2005.

Before starting patients with less severe depression on medication, DeRubeis suggests that doctors could recommend self-help books like “Mind Over Mood” or “Feeling Good,” proven alternative treatments like exercise or a better diet, or cognitive behavioral psychotherapy.

“Depression is a very serious problem, and the largest problem is that it is under-diagnosed and under-treated,” says DeRubeis. “We need to be sure that people who need treatment are getting treatment. But we also need to emphasize that it is not helpful to think of depression in simplistic terms, as a problem that must be addressed with medications.”

Instead of pointing the blame at overmedication, perhaps the focus should be on getting the most effective treatment for those in need. Or perhaps these recent findings just serve to clarify what is already known: that there is no singular solution to treating depression.

A book is in the works, addressing the issue of depression in Black gay men. I am in the process of collecting stories of Black gay men who have dealt with and are still dealing with depression, and placing these stories alongside what the professionals have to say about it, and what Black gay literature says about depression.

Lucinda

I would highly challenge the idea that Paxil and Prozac are on the same level playing field! I know so many who have had serious problems w/ Paxil and to use that as a test medicine is beyond me. There are so many SSRI’s out there that are different, ask any patient who has to wait 2 or 3 years just to find an effective one for them, that citing a study that only uses ONE seems absurd. I agree that I believe there should be no medicine without talk therapy but I have run into so many very, very poor therapist who use “talk therapy” that it’s almost like playing a dice game whether you get good care or not! No one tells what qualifies as “severe” and “less severe” depression either. So how would one, out of this article, find any guidance what so ever as to if they even should seek treatment? If you finally get to the point that you do seek help from a psychiatric practitioner, considering the stigma involved, it’s probably beyond just “read a book and you’ll feel better” time. Just speaking for myself, if I would have had someone stop throwing books at me and actually treat me as a medical patient, I would have had my situation take care of at a MUCH EARLIER time. No, medicine is not a panacea and neither should it be the only route taken but to say, “eh, if you’re not THAT sick, not gonna help anyway…” is terrible. It may be the difference between someone living and dying. I hate to say it but the article above, from the POV of a patient, was NOT on a “Need To Know” basis.

Robyn

I’ve tried to overcome my debilitating depression with meds and without. I can truly say that meds have given me my life back and therefore I am reluctant to stop taking them. Perhaps I am one of the fortunate ones. I have also added talk therapy which helps immensely too.

Kathy

I am now sadly and painfully aware of the pros and cons of medicating for depression/anxiety. I was part of the original double blind study on Effexor (Venlafaxine) at Penn back in the 90’s. This was in the days before the extended release version. My time in that study was a god forsaken roller coaster ride. I had no idea when I was getting the medication or the placebo. What I did get out of that study was HOOKED on Venlafaxine. And the non-extended release led to daily withdrawal…which was in fact the roller coaster ride. I had full blown panic attacks coming off of the medication and because I was part of the study, I had NO IDEA what was happening to me. That ride is one thing, but then the docs increase and decrease the amount to try to figure out what amount I really needed.
Not having the medication was NOT an option. In the years after the study, while still hooked on Effexor/Venlafaxine, I was finally offered the XR which helped — but I was still completely dependant. Running out of medication on a Saturday led to me being unable to cope with anything by Monday including my ability to even call my doctors.
I honestly think that ONE MEDICATION messed me up more than an abusive husband and the bad marriage that led me to the study in the first place. Why don’t we don’t talk about dependency when we talk about these things. I don’t think I ever needed medication before that time; and I wish I could live without them now?
Getting weaned off of the Effexor took me 2 years of trying and 4 doctors who each had different ideas about how to wean (including opening capsules and counting out grains of the insides). To think that some of those 4 doctors just wanted to increase the dose of the Effexor XR or add another med to the first one; or try the new version (different manifestation of the same venlafaxine—I forget the street name and the terminology, but it’s pre-processed /pre-digested or something?) Did they not hear me saying I didn’t want to be on it or feeling like that anymore? . I am now going on a year of ONLY being on PAXIL and I feel stable for the first time in probably 10 years; but, the idea of not being on anything still scares me as much as anything in the world. Holy cow?
It’s not the patient who is expected to know what is best—is it? Well it ought to be. It wasn’t until I said OUT LOUD, I can’t keep taking this medicine — it is messing with my life — that my primary care physician finally heard me and helped me figure out how to really get unHooked. Not to mention, I am certain that for those 10 years on that one medication, I lost most of my ability to show any profound emotion — good or bad. Now that I am off of that medication, I feel emotions again—some good and some bad, but at least I am not numb anymore. There is so much more to study about Mental Health. I truly believe that medications are too readily used without an understanding of the outcomes and longer term effects.

Sarah

For some people, neither prove (relatively) effective. I’ve tried the talk therapy, biofeedback, and been on an on-again off-again relationship with a plethora of pills. None really worked. The pills did cause me to drastically gain weight and send me into a coma-like personality. Not only are drug and talk therapy expensive, but both also take time. The only thing that has worked for me is telling myself I’ll be happy, even if I’m depressed. Even if I’m experiencing a panic attack. Drug therapy may be right for some people (if it weren’t there wouldn’t be an antidepressant ad on almost every commercial break), and talk therapy may be right for others. But surrounding yourself with positive people and attempting to have a happier (not necessarily happy) attitude can do wonders also.

Blue Monster

Nice to see depression the easiest thing to treat once again gains the spotlight. How about something on personality disorders or bi-polar disorder. Treatment both pharmaceutically and therapeutic can help but without financial or insurance resources most folks like myself have to make do. Fortunately I am inventive and creative enough to fight this battle alone, but I remember the days of getting both medication and therapy, and the battle wasn’t so hard. We need more funding, understanding, anyd removal of stigma for mental health to really be affective. Funny to think most insurances will cover erectile disfunction drugs almost completely over psychotropics. Why?

Kay

There should just be a better way! I’ve struggled with depression for years, tried meds, tried therapy, and now just hope every day I’ll get him by a bus or get sick. I’m resigned that things won’t get better. I will never understand how a therapist can look you in the eye at the moment you are most vulnerable and tell you that you should “read this book” to get better. READ A BOOK?? And a 500 page book?? They can’t even narrow it down to a few chapters? What are THEY getting paid for? If I could read a book to get better, I wouldn’t be in therapy!! I have a hard time getting off the couch and all I get from the $100+/hr therapist is “read this book” and maybe “you need to work on thinking positively”? No kidding. They should just tape a podcast – no reason to actually see a patient.

Elizabeth

Depression is multi-faceted in its origins — organic and contextual. Treating contextual depression with pills dismisses, really, the issue that the individual has something problematic in their life, not their body. Taking a pill may — stress on may — alleviate the feelings by altering the chemistry, but so would a glass of wine (which is why self-medication often occurs). Prescribing drugs in this situation really re-inforces the self-medicating behavior. The problem would be better addressed by discovering what is at issue.
Depression that is organic — chronic, life long, and life threatening — does benefit from proper medication along with therapy. However, the pills need to be monitored, as they have terrible side effects or cease their effectiveness after a point. It often takes a combination of 2 or 3 different medications along with therapy. Therapy isn’t just about talking about problems, it’s about how to live with a disease and manage moods.

fiona64

I was deemed a “medically resistant” patient after being tried on everything from older tricyclics to the most up-to-date SSRIs. None of those things helped, but did leave me with permanent and debilitating side effects. I have been reading up on neuroleptics/psychotropics since my initial diagnosis, and am reasonably convinced that they work for a small minority population. Unfortunately, with direct-to-patient advertising, people become convinced that if they just have the latest drug their problems will be solved — and studies have proven that people who ask for a drug are likely to get the very one they request. Gary Greenberg’s “Manufacturing Depression” addresses this and many other issues. I highly recommend it.

It’s easier and cheaper for insurance companies and HMOs to throw a pill at a problem than actually address it.

Chuck Biscuit

“For people suffering from depression, misinformation abounds.” Thank you for your own contribution to the misinformation. You have now convinced me that there is nothing else I need to know from you. If I want an unreliable source I will go to Wikipedia. (The comments readers have made here are insightful and far more informative than anything you have written.)

Peter Pine

Depression has many causes. Using medicine masks the symptoms, but does not help the underlying conditions. I won’t deny possible surface benefits.

If they could make a drug that would make rats happy no matter how cramped they were in a cage, or starved, or cold…if they could make a drug that would make us happy no matter how unjust the government, how many wars there were, how poor the air and water were… would you take a drug that would make you happy no matter how bad your conditions were?

Maybe we should trust our feelings when something is wrong…

“It is no measure of health to be well adjusted to a profoundly sick society.”
- J. Krishnamurti

Need to Know is a production of Creative News Group (CNG) in association with WNET. Marc Rosenwasser is Executive Producer. Need to Know is made possible by Bernard and Irene Schwartz, Mutual of America, Citi Foundation, John D. and Catherine T. MacArthur Foundation, Miriam and Ira D. Wallach Foundation, Margaret A. Cargill Foundation, The Corporation for Public Broadcasting and PBS.